functional abdominal pain

7/31/2019 Functional Abdominal Pain

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Morning ReportJune 11, 2012

Holly Shillington, MD, PGY-2


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The Case12 year old female in GI clinic with her father

presents with abdominal pain for one year.

Started May 2011 with a stomach flu (vomitingand diarrhea x 1 week)

Afterwards, she still had occasional abdominalpain, especially prior to dance competitions.

No pain over the summer.

Pain started again in August with school.


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Location: periumbilical, but often diffuse.7-10/10 pain, squeezing. Missed 30days of school this year.Lasts for hours.2 x weekly dailyTylenol, defecation doesnt help. Dancecompetitions make it worse.No association with menses, specific

foods, or eating itself.Often associated with nausea.


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Stooling: Has soft stools once daily. Nostraining. No bloody stools. No change inconsistency or frequency of stool.

Diet: Eats a balanced diet, including fruitsand veggies.


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ROS

Denies weight loss, fever, mouth sores,perianal sores, rectal bleeding, rash,diarrhea, dysuria, vomiting, or any otherconcerns. No trauma.


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PMH: Broke left arm in 2008

Meds: noneNKDAIMMS: UTD

Family Hx: Adopted, bio-parents arehispanic.


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Pre-Teen Only Interview

Never been sexually active. LMP one

week ago.Denies verbal, physical, sexualabuse.

No other concerns from patient.


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Dads Concerns

Describes daughter as dramatic andfears that stress may have a role in her

pain.Patient was too anxious to sleep by herselfuntil one year ago, and now she needs to

listen to soothing music to fall asleep.


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Objective

VS: T 37, HR 85, RR 16, BP 110/70, wt 43kg

PE: sitting upright, pleasant. No acutedistress. Exam is normal.


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DDX of Chronic Abdominal Pain


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DDX of Chronic Abdominal PainGI

Malabsorption/Lactose IntoleranceCeliac diseaseConstipationInflammatory Bowel DiseaseRefluxEsophagitis or Gastritis (peptic,eosinophilic, infectious)Peptic ulcerBezoarFunctional dyspepsia

AerophagiaIrritable bowel syndromeFunctional abdominal pain

GYNPelvic Inflammatory DiseaseEctopic PregnancyOvarian Cyst

NeurologicAbdominal Migraine

InfectiousGiardiasisUTI

Parasitic infection

Thyroid Disease


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Labs

Normal TSH, T4, CMP, ESR, CBC, UA,Celiac panel


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Functional Abdominal Pain

Defined by the Rome III criteria:Functional Abdominal Pain: episodic or continuous pain at leastonce a week for at least 2 months without evidence of an

inflammatory, anatomic, metabolic, or neoplastic process andwith some loss of daily functioning. Insufficient criteria for otherdisoders:

Functional Dyspepsia: epigastric painIrritable Bowel Syndrome: Onset associated with change in stoolfrequency or consistency, improvement with defecation.

Abdominal Migraine: 2 or more episodes of intense periumbilicalpain associated with 2 or more symptoms (anorexia, nausea,vomiting, headache, photophobia, pallor) in the past 12 months,separated by a symptom free period.


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Proposed MechanismAn earlier event (infectious, allergic,

inflammatory, tramatic, emotional) results insensitization of the GI tract leading toabnormal sensation and motor reactivity inresponse to normal stimuli (a meal, gutdistension) or psychologically stressful stimuli.Visceral Hyperalgesia


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Red Flags that may indicate an organic cause for chronicabdominal pain:

Dysphagia

VomitingWeight loss, fever, rash, mouth sores, joint painFMHx of IBD, celiac dz, or peptic ulcers.Impaired growthDelayed pubertyRebound, guarding, abd distension, abd mass, HSMPerianal dz (tags, fissures, fistulas)Blood in stool


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Work Up:If no red flags on a complete history and

physical, stool testing for occult blood isusually sufficient to exclude organicpathology.Additional testing should be guided by historyand exam.


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Treatment:Reassurance: Explain visceral hyperalgesia.

Can compare abd pain to headache as anailment that is commonly experienced and notusually associated with serious dz.Diet: Lack of evidence for high-fiber or

lactose-free diets for children with FAP.Antispasmodics: (ex. Levsin) Not shown to bevery effective in reducing chronic abd pain


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Treatment, cont:Peppermint Oil: Helpful! gut analgesic

Pills, tea, Altoids, Peppermint Patties.Cyproheptadine: Appetitie stimulant. Shown to beeffective in a double-blinded randomized placebo-controlled trial (Sadeghian, et al.)

Probiotics: Lactobacillus has found to be helpful.Psychological treatments: cognitive-behavioralstrategies, hypnotherapy, guided imagery, etc.


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Treatment goal is to decrease pain andreturn child to normal level of functioning.

Completely abolishing pain is not theexpected outcome, or even the goal. Thisshould be explained to parents andpatient.


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Case Wrap Up

Levsin 0.125 mg SL q 6 prn crampingIf needing Levsin more than a few times a week,may consider starting amitryptiline.Melatonin 3 mg qHS for sleep and to decreasevisceral hyperalgesia.Must go to school, despite pain.Counseling for coping strategies and relaxationtechniquesFollow up in 4 months


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References

Almadhoun, O. (2012). Managing Chronic AbdominalPain in Children. Contemporary Pediatrics . Vol. 29, No.3, 18-23.

Evaluation of the child and adolescent with chronicabdominal pain Up To Date . 7 June 2012Management of the child and adolescent with chronicabdominal pain Up To Date . 7 June 2012.Sadeghian, et al. Cyproheptadine for the treatment of

functional abdominal pain in childhood: a double-blindedrandomized placebo-controlled trial. Minerva Pediatr .2008;60(6):1367-1374.

functional abdominal pain

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